Income Protection Claim Form - New Ireland Assurance

Income Protection
Claim Form
Protection
BLOCK CAPITALS to be used throughout or tick (3) where appropriate. Answers should be continued on a separate sheet if necessary.
Policy No.:
Please answer the following questions fully. It is important that each question asked is answered and that no blanks are left. Failure to
provide full information may delay consideration of your claim. If you fail to disclose a material fact or if you give false information, you
could render your insurance void. Material facts are those which an Insurer would regard as likely to influence the assessment of your
claim for disability benefit. If you are in doubt as to whether certain facts are material, such facts should be disclosed.
Please return this form to: Claims Team, New Ireland Assurance, 9-12 Dawson Street, Dublin 2. Should you have any queries or
require any assistance in completing this form please do not hesitate to contact us on 01-6172974.
1. Personal details
Name:
Address:
D D M M Y Y Y Y
Date of Birth:
Home Telephone No:
PPS Number:
Mobile Telephone No:
Email:
Job Title:
2. Occupational Details
Please tick as appropriate:
Are you Self-Employed/Company Director (please start at question 1 below)
Employed
(please skip to question 2 below)
1. If you are Self Employed or a Company Director, please provide the name and address of your business.
A) Do you have any employees? Yes No
If yes, how many?
B) Has your business ceased operations? Yes No
C) Does your business continue to generate any income? Yes No
D) For how long have you been Self-Employed/Company Director Years Months
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If you have answered Question 1 A - D Please skip to Question 4
2. Name and address of your Employer at the time your disability commenced.
3. How long have you been with your current employer? Years Months
4. Is your employment Full time
Part time
Job Share
5. How many hours per week do you work? Hours
6. On what date did you last undertake any part of your job?
D D M M Y Y Y Y
7. During an average working day, what % of time would you spend doing the following activities?
Sitting % Typing %
Walking % Lifting %
Bending % Driving %
Other physical activity % Please describe
8. Please provide a description of your normal
working duties, i.e. what are the main duties you
have to perform in your role?
9. Are you still an employee of your company? Yes No
If no, please provide further details.
10. Is the job you were performing still open to you when you recover? Yes No
If no, please provide details.
11. Have you discussed future employment or rehabilitation with your employer? Yes No
If yes, please provide details.
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2. Occupational Details Cont.
12. When was your last contact with your employer?
D D M M Y Y Y Y
13. On what date do you expect to be able to resume work?
14. Have you undertaken any other work (whether paid or unpaid) since commencement of disability? Yes No
If yes, please give full details.
3. Financial Details
1. What were your gross taxable earnings in the 12 months immediately before your disability? @
2. Are you in receipt of any other income from any other sources? If “yes”, please provide full details:
A) Your employer
B) A second job
C) State Illness Benefit
D) Other sources
3. Do you have any other insurance policies where benefit becomes payable as a result of your inability to work?
If so please provide details:
Company Name
Policy Number
Sum Assured
@
Deferred Period
Have you submitted a claim? Yes No
Is this claim in payment? Yes No
Should you have more than one policy, please provide the details above on the notes section page 6.
4. Medical Details
1. Please describe in detail the nature of the disability from which you are suffering, including any diagnosis.
If your disability is the result of an accident, please provide details.
2. When did you first experience symptoms related to your disability and what were these symptoms?
3. Have you previously had the same or similar condition? Yes No
If yes, please confirm dates and duration of illness.
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4. Medical Details Cont.
4. Please provide details of any previous absences
from work due to your illness/disability.
5. When did you first seek medical advice about your
disability?
6. Please provide details of any medical investigations,
either as an inpatient or outpatient, and any
specialist referrals in respect of your disability.
7. What treatment, medication or therapy are you
currently receiving? Please include dosage.
8. Is your current treatment providing any relief from symptoms? Yes No
If yes, please provide details.
9. Please describe the duties/activities relating to
your normal occupation that you are unable to
carry out as a result of your disability.
10. Please describe the duties of your normal
occupation that you can still perform.
11. Details of doctors/specialists, in connection with this condition.
GP:
Name:
Address:
Contact No.:
Your main treating Consultant:
Name:
Area of Speciality:
Address:
Contact No.:
Date Last Attendance:
D D M M Y Y Y Y
Date Next Attendance:
D D M M Y Y Y Y
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4. Medical Details Cont.
Consultants & any other medical practitioner attended:
Name:
Area of Speciality:
Address:
Contact No.:
Date Last Attendance:
D D M M Y Y Y Y
Date Next Attendance:
D D M M Y Y Y Y
Consultants & any other medical practioner attended:
Name:
Area of Speciality:
Address:
Contact No.:
Date Last Attendance:
D D M M Y Y Y Y
Date Next Attendance:
D D M M Y Y Y Y
12. Have you attended any other doctors in the last Yes No
5 years? (If yes, please provide details).
13. Have you, are you, or do you intend making a claim for compensation against a third party Yes No
in respect of your disability?
If yes, please provide further details.
5. General Information
Please provide any additional information you feel would assist us in assessing you claim.
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7. Bank Account Details
Please provide details of your bank account to which payments should be made:
Account Holder Name:
Account Number (IBAN):
Swift BIC:
(your bank will be able to confirm these details if necessary)
Please note that payments will only commence to be made following acceptance of your claim by New Ireland Assurance.
8. Checklist
Please tick box to confirm that the requested information has been enclosed:
Copy of Passport/Driving Licence/Birth Certificate
Detailed Job Description
For Employed Persons (no requirement if the confirmed income option has been chosen):
Most recent P60
Copy of last 3 months salary slips
For Self Employed Persons (no requirement if the confirmed income option has been chosen):
Copy of three previous years Notice of Assessments
A copy of the most recent Audited Accounts (e.g. Company Accounts or Partnership Accounts as appropriate)
9. Declaration and Agreement
I declare that to the best of my knowledge and belief the information given in this Income Protection Claim Form is true and complete and I
have not withheld any material fact.
Please note on receipt of this claim form we will assess the claim and will communicate with you when this has been completed.
I fully understand that I must notify New Ireland Assurance immediately if I resume my normal occupation on a full time or part-time basis,
or if I take up alternative work (whether paid or unpaid) as failure to do so will result in my claim being rejected or payment being terminated
and cover ceasing.
I consent to New Ireland Assurance seeking information in connection with this claim form from any source the Company deems necessary
and I authorise the giving of such information.
I understand and consent that New Ireland Assurance and its duly authorised agents may hold and use the information on computer file,
in any other dematerialised form or in written hard copy on it’s own behalf and may use or pass the information to third parties (including,
where relevant, private investigators) for matters in connection with the investigation and processing this claim and for administration,
regulatory, customer care and service purposes. I agree that New Ireland Assurance or a duly authorised agent of New Ireland Assurance
may contact me in person, by phone, by email, or by letter.
“Information” means any information including medical and non-medical information given by me or on my behalf in connection with this
claim or any further information which may be given at a later stage either in writing, by email, at a meeting or over the telephone.
I consent to New Ireland Assurance seeking information from any doctor who at any stage has attended me concerning anything which
affects my physical or mental health or seeking information from any insurance office to which a claim has been made by me and I authorise
the giving of such information.
@
Signature of
Claimant:
Date
Signed:
D D M M Y Y Y Y
New Ireland Assurance Company plc.,
9-12 Dawson Street, Dublin 2.
T: (01) 617 2974 F: (01) 617 2487.
E: ClaimsNI@newireland.ie W: www.newireland.ie
New Ireland Assurance Company plc is regulated by the Central Bank of Ireland. A member of the Bank of Ireland Group.
301474 V4.10.13
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